- Email: [email protected]
Using the Internet for Research
REVIEWS
Using the Internet for Research Bill G. Felkey and Shauna M. Buring
Objective: (1) To give an overview of research tools, techniques, and resources that are available on the Internet; and (2) to identify valid, pharmacy-related information that will reduce uncertainty in the problem-solving activities of practitioners. Data Sources: The World Wide Web. Study Selection: Examples cited in the article were evaluated according to the criteria offered in the text as a pre· requisite for their inclusion. Data Synthesis: Functional aspects of the Internet include communication, commerce, and content. Because a lack of control has led to mixed information quality, the use of Internet-based information for patient care and professional ,
I
decision making should be subject to rigorous screening criteria. Pharmacists can use Web browsers combined with excellent search engines and search techniques to identify quality resources, including primary, secondary, and tertiary literature, either fee-based or free, and that can be sought actively or distributed on a schedule directly to the desktop of the pharmacist. Conclusion: The Internet can be an immensely helpful research tool, if used appropriately. Whether actively searching or passively receiving useful updates, the Internet can function as a value-added asset to any pharmacy practice. JAm Pharm Assoc. 2000;40:546-53,
The pharmacist often serves as an information resource for patients and other health care professionals. Patients are increasingly bringing Web-based material to their pharmacists to interpret and evaluate, and to personalize its application to their lives. Unique opportunities exist for pharmacists to position themselves as the information purveyor on interdisciplinary health care teams. Assuming this role requires that pharmacists become highly skilled in the area of Internet research. This article is intended to help readers incorporate the Internet into their practice for the purpose of achieving greater efficiency, effectiveness, and satisfaction. The article focuses on those resources in the area of health care in general, and pharmacy specifically, that are readily available for practitioners' use.
Internet Functions The functions of the Internet can be categorized into the three C's: communication, commerce, and content. Communication is Received February 14, 2000, and in revised form April 30, 2000. Accepted for publication May 4, 2000. Bill G. Felkey, MS, is associate professor of pharmacy care systems; Shauna M. Buring, PharmD, is assistant professor of clinical pharmacy practice, School of Pharmacy, Auburn University, Auburn, Ala. Correspondence: Bill G. Felkey, MS, Auburn University, Department of Pharmacy Care Systems, 128 Miller Hall, Auburn University, AL 368495506. Fax: 334-844-8307. E-mail: [email protected].
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interchangeably referred to as connectivity andlor community, Commerce encompasses both business-to-business and businessto-consumer transactions. Content is an increasingly rich resource for reducing uncertainty in decision making as long as ) the pharmacist is aware of the quality issues associated with the content. Pharmacists must become skilled in identifying and separating the good from the bad.
Communication When most people think about communication via the Inter- 'I' IT net, they likely think of e-mail. However, the Internet provides communication capabilities that are far more sophisticated than simple messaging. Videoconferencing, chat rooms, news broad· ) I! casts, radio programs, and continuing education programs are 1p among the additional communication formats available. The u communication devices used to access the Internet continue to ~ weigh less and do more. Telemedicine technology and desktop u videoconferencing have been part of the reason that futurists P have proclaimed, "Death to Distance!"l In the United States, d Western Europe, and Japan, communication technologies have ~ become so integrated in daily life that computer illiteracy is anal- h ogous to an inability to drive a car. Being online full-time is rapidly becoming a requirement as basic as having a telephone. As health care becomes more "Net- ) ~ centric," or Web-based, these communication capabilities will continue to change the face of pharmacy until they are integral to
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Using the Internet
successful and competitive practice. The clinical workstation to be used at the point-of-care, or the point at which the health care I practitioner interacts with a patient or colleague, can be a desktop computer, portable computer, palm computer, or even a wireless, portable system. A practitioner can begin incorporating the power of information technology and the Internet by selecting core medical and drug information references (e.g., Harrison's Online, Micromedex's DrugDex), creating a connection to the Web, and selecting additional clinical resources that are appropriate for daily practice (an example for patient education is www. healthanswers.com and for clinical practice guidelines, . www.guideline.gov). It would also be desirable to use a highbandwidth connection to the Internet, such as cable modem or digital subscriber line, if available. I I
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Commerce (Mouse-to-House) Internet commerce is expected to continue to increase rapidly. In a recent online poll, 50% of the respondents had made an online purchase within the past 12 months, and 71 % planned to increase their use of the Internet as an e-commerce tool in the future. 2 The Internet is exploding, with news agencies reporting $5 billion in sales on the W orId Wide Web during the 1999 holiday season ~one. 3 Medical reference books, durable medical equipment, and medications (both"prescription and over-the-counter) are all availI able with the click of a mouse and a credit card.
IContent I
In 1998 Bill Gates, in a keynote speech for the Redmond, Washington, Conference on Information Technology, predicted that by the end of 1999 the Internet would hold more information than exists in the entire history of print for mankind. As of mid2000, there are more than 800 million Web pages. However, although the amount of content to choose from on the Internet is overwhelming, there are many ways to make the search process more efficient. The amount of medical and pharmaceutical information available on the Internet, for both health care professionals and patients, is immense-proprietary references, governmental information, practice guidelines, and a wide array of visual assets that can be Used to educate patients. Many major publishers have already converted their print resources for online access and made these offerings available on the Internet. Not only the text, but many of the previously offered CD-ROMs and network-version references and decision-support information resources are either currently or are SCheduled to be offered in a Web-based format. The next frontier is the integration of these content sources directly into practice illanagement and the electronic patient record, so that practitioners will not have to switch between programs to acquire the knowledge necessary to make decisions and solve problems. Remember that the intended purpose of all information is to reduce uncertainty. Effective Internet search strategies can help
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pharmacists locate key pieces of information to solve clinical problems. For example, often information is needed from the Food and Drug Administration (FDA) regarding new product approvals or market withdrawals. One can use a search engine and find the Center for Drug Evaluation and Research on the FDA home page (www.fda.gov/cder), then explore FDA's drug approval list for the time period of interest. While on this Web site, the user could also elect to receive information from the FDA on a daily or weekly basis. Knowing when the Internet should not be used for research is another valuable trait of the Internet researcher. Because of the relatively recent emergence of the Internet, Web sites may lack some historical information. Also, difficulty may be encountered when targeting news-related stories from proprietary sources that view the Internet as competition to their print publications. Some media publishers simply will not move their print products to electronic formats. However, this is expected to change over time, as the economic models on the Internet adjust. Information Quality
Evaluating the quality of information gleaned from the Internet is a crucial task for the Internet researcher. Because virtually anyone can post information on the Internet, it is important that health care providers view all information as suspect. Source credibility can be difficult to ascertain, but it must be verified. Furthermore, despite the broad perception that there are major inaccuracies in the health care information on the Web, designing research to study this problem is difficult. Evaluation of a large number of health care Web sites for accuracy is extremely time consuming, and there are no good studies published on this topic yet. The problem is more complex, and more urgent, because today patients are more involved in their own health care and frequently present information they have found on the Internet to their health care providers. Clinicians must be able to validate and screen this information for accuracy and appropriateness. Often, bias can creep into some information sites; therefore, it is important to know who is supplying the medical and pharmaceutical information and where the content originated. Site owners may have a vested interest in the content and hence give unbalanced information or promote individual products without divulging ownership of these products or other conflicts of interest. Therefore, users should know what to look for when evaluating the quality of a Web site. Below are specific items to look for or evaluate: • Authorship of the Web page and credentials of the content authors. • Quality of the references displayed with the content. Clinical information given with no reference to the source should receive low weight in clinical decision-making. • Disclosure of sponsorship and ownership of the Web site. • Frequency of updates, duration of time before important discoveries are incorporated into the content. • Presence of an expert advisory board that examines or evaluates content before it is displayed on the site.
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• Presence of seals of approval awarded by organizations that actively review health care Web sites (e.g., Health on the Net Foundation HONcode [www.hon.ch]; Internet Healthcare Coalition [www.ihealthcoalition.org]; VIPPS [www.NABP.com]; and Medical Matrix [www.medmatrix.orgD.5- 7 • Affiliation of the Web site--commercial, governmental, educational, nonprofit, military or from an Internet service provider. Although these designations will not guarantee the source validity of the content on a Web page, they can give some indication of the source's credibility. 4
Internet Research Tools and lips Table 1 lists the selected Internet research resources described in this section. When other resources are desired, it is important to know how to effectively locate, organize, and evaluate them. A browser is the software application that allows a computer to navigate the World Wide Web. Microsoft's Internet Explorer 5 and Netscape's Navigator and Communicator, both offered free of charge, dominate the highly competitive browser market.a,b The similarity in features and benefits to end users of the two leading browsers enables users to go back and forth between the two applications with little difficulty. Knowledge of search engines is crucial when performing
research on the Internet. Search engines help users locate individu- I al Web sites by entering keywords, culminating in a list of sites that contain information related to the keywords. Most search engines have combination approaches that cross-reference key- I words and/or topic areas to assist users in fmding the most relevant I Web sites. Some search engines (e.g., AltaVista at www.altavista.com) have special features that allow Web sites 'I developed in a foreign language to be translated into English. AltaVista (see Figure 1) currently translates Web site contentto and from English, Spanish, German, Portuguese, Italian, and French. Mega-search engines (e.g., Metacrawler at www.metacrawler.com, Dogpile at www.dogpile.com) combine , several popular search engines into one research tool, pooling the top hits from each search engine. Because each search engine uses a different logic, using the Help feature teaches the user how to best employ the engine and fine-tune the results. These tutorials typically require only a few minutes and will save the user time later. Most search engines offer basic and advanced search windows, the ability to filter out undesirable characteristics of a site, and allow the use of Boolean operators, such as "and," "or," and "not" to further refme searches. Another timesaving tip when researching for the Internet is knowing how to locate the exact text keyword on an extensive Web page. A search may identify a promising site, but the user finds it contains 20 pages of text. By simultaneously pressing the "etrI" I
Table 1. Internet Research Resources Resource Category
Web Site Address
Features
Market research on health care topics
www.cyberdialogue.com/resource/ datawh ite_pa pers/1998/ma rketi ng_ cyberspace.html
White papers and survey results
Health care Web site seals of approval
www.hon.ch www.ihealthcoalition.org www.medmatrix.org
Valid Web information
Search engines
www.altavista.com www.metacrawler.com www.dogpile.com
Keyword and "meta" searching using a variety of search engines
Primary and secondary literature tools
www.nlm.nih.gov/databases/freemedl.html www.ovid.com/index.cfm www.nlm.nih.gov/databases/freemedl.html uncweb.carl.org uncweb.carl.org/reveal tendon.nlm.nih.gov/ld/loansome.html www.silverplatter.com/catalog/ipab.htm www.silverplatter.com/catalog/idis.htm webmedlit.silverplatter.com/index.html
Identify and/or retrieve full-text, peerreviewed literatu re
Tertiary literature
www.micromedex.com statref.tetondata.com www.mdconsult.com cp.gsm.com www.dynamicmedical.com
Monographs, textbooks, references
Health care news and issues services
www.usatoday.com/life/health/health.htm www.cnn.com/HEALTH www.msnbc.com/news/HEALTH_ Front.asp ?ta=y www.entrypoint.com www.intelihealth .com
Information for browsing or automatic notification
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Using the Internet
Figure 1. These sample screens illustrate the free translation capability of AltaVista's search engine by taking German text from an alternative medicine site and translating it into English. Caution should be used, because the translation may not be 1000/0 accurate. Some sentences can be poorly constructed by the application.
REVIEWS
Saving Web addresses requires some restraint, because hundreds of site addresses can be saved in a very short time. Also, both browsers offer the opportunity to organize these bookmarks into category folders. Each time the user locates a Web site that relates to a research interest, the browser allows that bookmark or favorite to be placed into the folder. Without this level of organization, it is easy to scroll through hundreds of Web sites looking for one found previously but not saved to a folder.
Access to the Scientific Literatu re ~.' f.t~..~ I.tOfMllri.tt4l",\t1\4.""n'l~h' fl,h'-itYl.I\t!ft\ll8ldlhi ft .tttItl4t'Wtittih
Primary Literature
Many reputable journals are published with open access on the Internet. Additionally, corporations (e.g., M OVID) are supplying full-text online access to key medical and pharmaceutical journals. Many health care providers gain access to MEDLINE via the OVID platform (www.ovid.com) and thus are provided with full'''''.'iitflllh, text access to a number of the most widely read medical journals. Providers should contact their medical librarian to determine which resources are available. Colleges of pharmacy may also allow preceptors and adjunct faculty members library privileges. However, many health care professionals access MEDLINE through the National Library of Medicine's (NLM ' s) PubMed platform (www .nlm.nih. govI databases/freemedl.html), which is free. Unfortunately, PubMed does not offer direct access I ;: to full-text articles online. UnCoverWeb and Loansome Doc are fee-for-service companies that supply full-text primary literature to a ... 1\' .. fax machine and/or desktop computer. UnCoverWeb (uncweb.carl.org) is an online article delivery service. . .. ... More than 8 million articles are available through a sim.......... ....... .*'i ple online order system. Through this site, a user can ri""' •. order journal articles online for a fee; the article is then ~~--~~~--~~~-----~~--~~~~~--~~~~~~~ ~ ~~------~----~~.~-~--~-----------------=~-~ faxed to the requester. Acquiring an article from the primary literature through UnCoverWeb costs $10 per article plus the copyright fee. Some medical libraries subsiI and "F' keys, a Find window will appear. Entering a keyword in dize this cost for authorized users. that text window and clicking the Find Next button highlights the A similar service, Loansome Doc (tendon.nlm.nih.gov/ldl keyword( s) being sought. This feature works on personal comput- loansome.html), is offered by NLM as a feature of PubMed. Users ers in both Internet Explorer and Netscape Communicator. can log into PubMed, search MEDLINE, and then order articles Sometimes, stopping an Internet research session is more diffi- from Loansome Doc. Loansome Doc users must first establish an I cult than starting one. When performing research on the Internet agreement with a medical library that uses DOCLINE, MEDfor a specific topic, it is not uncommon to fmd material that is of LINE' s automated interlibrary loan request and referral system. interest not only for the present search, but also for other topics. The user can then order articles from a list of retrieved citations I Internet Explorer and Netscape Communicator have a feature that and have full-text documents sent to the library. Some libraries I allows users to "bookmark" these sites for future research. Users may then transmit the article via the Internet, e-mail, or fax. The Can return to Web sites by creating and clicking on a bookmark. cost of the full-text article varies from library to library. UnCover Reveal (uncweb.carl.org/reveal) allows the health I In Microsoft's Internet Explorer, this feature is called a favorite. ~ ~.ttt"t'ttMd\t!till .. lhtolt!'l'lh)ntlft."
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Vol. 40, No.4
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Using the Internet
care professional to track the tables of contents of up to 50 journals. Each month an e-mailed notification of the tables of contents for selected journals is sent. This service can cost as little as $25 per year and is offered free in some library systems.
Figure 2. Medical Matrix (WlNW.medmatrix.org) presents researchers with ranked, peer-reviewed resources identi· fied from the Web. The credentials of the editorial board are disclosed and the service is free. Registration is required.
Secondary Literature
Secondary literature includes the abstracting and/or indexing services that organize millions of articles published in the primary literature. These resources include both proprietary and governmental resources (see Figure 2). The most frequently used database in medicine is MEDLINE (often searched by the PubMed search tool). PubMed provides access to the indexes and abstracts of more than 4,300 biomedical journals. It was developed in conjunction with publishers of biomedical literature as a search tool for accessing the primary literature and linking to full-text journals at Web sites of participating publishers. Other databases that are commonly used in pharmacy include International Pharmaceutical Abstracts (IPA) and the Iowa Drug Information Service (IDIS). IPA (www.silverplatter.com/catalog/ipab.htm) is a disciplinespecific database that indexes pharmaceutical science- and healthrelated journals and is available online as a component of the OVID platform. IDIS is a full-text database; the articles are stored on CD-ROM or microfiche (www.uiowa.edu/-idis).IDIS extracts articles from 190 leading medical and pharmacy journals. There are also many disease-specific databases that can be used in an Internet searching strategy. AIDSLINE (www.silverplatter. com/catalog/aidl.htm), which is supported by NLM, includes citations to the literature covering research, clinical aspects, and health policy issues related to AIDS. The citations are derived not only from journals, but also from AIDS-related meetings, such as the International Conference on AIDS. Commercial vendors such as WebMedLit and Medscape offer less traditional databases. WebMedLit (webmedlit.silverplatter. com/index.html) provides easy online access to the some of the best medical journals. The vendor scans selected medical Web sites each day and extracts the available citations, abstracts, and full-text articles. WebMedLit is arranged by disease state for easy searching. Medscape (www.medscape.com) is a multi-specialty medical information and education tool. Segmented by specialty, Medscape scans, filters, and collates pertinent content from online journals, summaries of professional meetings, and news in various specialty areas, including cardiology, internal medicine, and psychiatry. The National Guideline Clearinghouse (www.ahcpr.gov) is a comprehensive database of evidence-based clinical practice guidelines and related documents produced by the Agency for Health Care Policy and Research, in partnership with the American Medical Association and the American Association of Health Plans. Their mission is to provide health care professionals with information on clinical practice guidelines and to further the dissemination,
550 Journal of the American Phannaceutical Association
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implementation, and use of these practice guidelines. The National Guideline Clearinghouse can be an immensely useful tool in Internet research. The number of guidelines published by various professional organizations and governmental agencies is growing quickly. This resource helps users keep track of these guidelines by collating them in one site and organizing them by disease state.
1
Tertiary Literature
The category of tertiary literature includes review articles, textbooks, compendia, and full-text computerized databases. The advantage of using tertiary references is that the information has already been reviewed and condensed, so it is usually more compact and easy to examine. Historically, the disadvantage of this type of information was that it could be up to 3 years old before a new edition would be published. The Internet, however, makes it possible to update full-text tertiary databases on a daily basis, Before making patient care decisions based on the information contained in any resource, users should be confident concerning the source's credibility. There are many excellent proprietary references that are fee-based. Sponsorship has made it possible for other respected sources to be accessed free-of-charge. Additionally, an increasing amount of information categorized as news or medical issues information is being published on the Web. This is valuable for its "current awareness" value as well as for positi~n- ) ing pharmacists to discuss late-breaking health care issues WIth patients in a timely manner. Fee-based Resources. Fee-based tertiary literature in electronic formats was previously available only on CD-ROMs or network servers. Publishers have rapidly been creating Intranet versions of their products. The advantage of this kind of version is
July!August 2000
Vol. 40, No.4
Using the Internet
the global access to the information with a valid ID and password. For example, the Micromedex product DrugDex (www. micromedex.com) has extensive drug information monographs that list the primary literature used to write the monograph. Other Micromedex databases included in the Micromedex product make it valuable for the emergency department physician and setting. Another database, STAT-Ref by Teton Data Systems (statref.tetondata. com) , contains more than 30 internationally recognized tertiary references. The product is available for Internet access and is capable of giving users access to one or all 32 references on any search. The references can be purchased individual) ly or in sets and placed on the health system Intranet for use. M.D. Consult (www.mdconsult.com) is the Internet product that contains the medical holdings of three large publishers, Lippincott Williams & Wilkins, Mosby, and W. B. Saunders Company. The product, which can be licensed by individuals for approximately $20 per month, contains more than 50 tertiary references, more than 500 published practice guidelines, patient education material, and more than 60 full-text journals. A 10-day free trial allows Internet researchers to examine the information offered before subscribing to the product. Free Online Resourcesrrextbooks. Hundreds of sites offer tertiary literature free-of-charge to both health care professionals and patients. Gold Standard Multimedia, Inc., (www.gsm.com) now offers Clinical Pharmacology 2000, which includes full-text drug infonnation monographs, free online, because their site is supported by advertising. This business model is likely to be followed increasingly, enabling access to information sources that would previously have cost several hundred dollars for a print I
publication or CD-ROM version of the same information. DynaMed (www.dynamicmedical.com). a free, disease-oriented Web site, is produced by physicians and other health care professionals as a point-of-care decision support tool (see Figure 3). The site displays a concise review of some 2,000 diseases and connects the user to other full-text journals and practice guideline resources on the Web. The National Institutes of Health has assembled a Web site for the National Center for Complementary and Alternative Medicine (nccam.nih.gov) that helps to address the need for an evidence-based approach to complementary and alternative medicine. This site is based on more than 180,000 primary literature references. Much of the clinical information presented on professional association and governmental sites is considered tertiary literature. In general, there is no fee for accessing this information. For example, the National Digestive Diseases Information Clearinghouse ( www.niddk.nih.gov/health/digestlnddic.htm) presents an overview of gastroesophageal reflux disease in a question/answer format that is quite descriptive. Some sites may be valuable for a health care provider's own edification or for referring patients who are eager to learn more about their conditions. One of the more recent developments on the Internet is the availability of free online textbooks. While many users prefer to have a print copy, online textbooks are valuable resources for reading limited amounts at one sitting. For example, a clinician seeking a refresher on the specific pathophysiology of esophageal motility could access Gold Standard Multimedia's online textbook Essentials of Human Physiology at imc.gsm.com. Because there is no one specific site that houses many online textbooks, search engines should be used to identify online texts in specific interest areas.
Figure 3. The DynaMed site offers a succinct, point-ofcare database that is updated daily. It addresses the management of more than 2,000 diseases and is free-ofcharge. ICD-9 codes, therapy considerations, etiology, and other subjects are addressed.
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Current Health Care News The mainstream and trade media frequently cover reports from major medical journals, such as JAMA and The New England Journal of Medicine. Additionally, many television news programs cover health care-related issues and often break stories that generate significant concern among the public. Therefore, it is important for health care providers to stay abreast of what the media reports to the public. One way of accomplishing this task is by reviewing a national newspaper or television site for the day' s health care issues. Print subscriptions are not necessary to access USA Toda y online (www. usatoday.com). Also, bookmarking the Health page provides quick access to the newspaper area of interest. Additionally' Cable News Network (CNN) (www.cnn.com) is a good Web site to use as a barometer of the health care issues before the public. The Internet is also valuable for accessing other topical programs, such as Dateline on MSNBC (www.msnbc.com). For example, Dateline recently aired a show about an autistic boy who was
Journal of the American Phannaceutical Association
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Using the Internet
given Secretin during an endoscopy and showed amazing improvement after the procedure. Shortly after this airing, pharmacies were flooded with questions about the product. Transcripts from the Dateline episode are available online and are extremely useful in such situations.
Figure 4. InteliHealth by Johns Hopkins offers a compre· hensive set of databases for consumer and practitioner use. It can send daily e-mail notices on health subjects of interest through a registration process. It contains special interest areas such as the women's health resources illustrated.
Push Technology It is easy to become overwhelmed by the amount of information found when searching the Internet. Hence several services personalize information and send it automatically or on demand. This service is called a "dialogue transaction" or "push technology," because the information is "pushed" by the service. EntryPoint (www.entrypoint.com). formerly PointCast, is a free service that allows you to select health care information and breaking news, information on pharmaceutical manufacturers, as well as sports, weather, financial information, and news about the Internet. By completing a filter form online, a user can request that information be limited to his or her interests. Johns Hopkins University and InteliHealth.com (www.intelihealth.com) offer a similar service that contains both professional and patient information for browsing, or users can fill out a profile and receive a daily e-mail containing news and developments in a given area of interest (see Figure 4). It is expected that this type of information dissemination will continue to increase as the Internet develops.
Fair Use and Copyrights Not all of the information on the Internet is in the public domain, even though the Internet can be readily accessed most anywhere on the planet. Many text and nonprint assets, such as pictures, sounds, and video vignettes, carry copyright protection. Much of the material on the Internet can still be used in a variety of different ways in practice. However, when the material captured from the Internet is used in a commercial venture, the line has been crossed between fair use and the need to pay a fee to the copyright holder. For example, many companies place information on the Internet that can be of value as a patient education resource. Using it directly from the Web site would not require any citation or attribution. However, copying the picture or quoting a portion of the material and combining it into your original work would require you to cite the author of the material and note the Internet address where the material originated or was acquired. When concern arises about whether something is a fair use, it is easy to use the e-mail feature on a Web site to request permission from the copyright holder. This usually entails a description of the intended use of the material. Use of the material in a commercial venture, such as creating a for-profit program for sale on the open market, will probably require the payment of a licensing fee. The
552
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United States Pharmacopeial Convention's Web site (www.usp.org) provides an example of a clear explanation on this line between free use and licensing. Although much of the content of their Web site is viewable by subscribers only, the site also contains quality photographs and useful information about dietary supplements that clinicians can download and use. At the bottom of their Web site is a Terms of Use section that informs the user that all materials are copyrighted. Any software downloaded from the site, including any files or images, and data are licensed by the United States Pharmacopeial Convention, Inc. It is stated that users are not allowed to "redistribute, sell, decompile, reverse, engineer, disassemble or otherwise reduce the software" to another format. 5 They further assert that this assumed agreement can only be superseded by an acknowledgment from them in writing that the requester has permission to use some of their content.
Conclusion The Internet can be an immensely helpful research tool if used appropriately. Whether one is actively searching or passively receiving useful updates, the Internet can function as a "valueadded asset" to a pharmacy practice. Learning when to use it, hoW to search for sites of interest, how to evaluate sites, and gaining insight into how the Internet can be used in practice are essential to the successful use of the Internet as a research aid.
----------------------------------------------- -Authorship of the article occurred following a consultancy to develop a PowerPoint presentation for Janssen Pharmaceutica through Carnes Communication for future presentations on the topic. The authors declare no
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Using the Internet conflicts of interest or financial interests in any product or service mentioned in this manuscript, including grants, employment, gifts, or honoraria.
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References
Footnotes aMicrosoft Internet Explorer 5, the newest version of Internet Explorer is available at: www.microsoft.com/windows/ie/. bNetscape Communicator offers the complete set of tools for browsing dynamic Web content, and provides full-strength e-mail. Netscape Navigator is a browser that allows you to view Web sites. Available at: www.netscape.com/download/prodinfonfs_1.html.
1. Photo-News [Web sitel. Photofinishing News Letter. 1999;17(06). Available at: www.photo-news.com/pnI/1999-pnI/91122-PNL.htm. Accessed April 28, 2000. 2. Cyber Dialogue [Web sitel. Marketing Research in Cyberspace. Available at: www.cyberdialogue.com/resource/data/white_papers/ 1998/marketing_cyberspace.html. Accessed April 29, 2000. 3. PC Data Online [Web sitel. Consumer Internet Spending Tops $5 Billion During Holiday Season. Available at: www.pcdataonline. com/press/pcdo11300.asp. Accessed April 29, 2000. 4. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: caveat lector et viewor-Iet the reader and viewer beware. JAMA. 1997; 277:1244--5. 5. United States Pharmacopeia [Web sitel. Terms of Use. Available at: www.usp.org. Accessed February, 09, 2000.
Demise and Rebirth of Prescription Compounding in American Pharmacy Advances in science and technology during the 1900s led to the large-scale production of pharmaceutical preparations and dosage forms. As a result, phannacists compounded less and less. About 60% to 80% of all prescriptions were compounded during the 1930s and 1940s, but less than 1% required compounding during the 1960s. Hospital pharmacies began compounding intravenous solutions in the early 1970s. Currently, millions of large and small volume containers of parenteral solutions are compounded annually by trained technicians under the supervision of hospital phannacists. Gosselin 1 reported that in 1995 about 11 % of 220 million prescriptions were compounded in pharmacies that specialized in this activity. Two organizations 2 claiming thousands of members and franchises are based in Houston and assist pharmacies who wish to specialize in prescription compounding. Some phannacy schools 3 offer elective courses in prescription compounding, a recognized specialty in some states. During the last 15 years some hospital and community pharmacies "batch-compounded" prescriptions or preparations in quantities larger than those usually dispensed to an individual patient. In an attempt to define and perhaps regulate this kind of compounding, the Food and Drug Administration Modernization Acfl came into being in 1997. This act has become a congressional issue, and has triggered discussions among state boards of pharmacy and professional associations trying to protect the traditional compounding activities of phannacists. A Phannacy Compounding Advisory Committee has been appointed to make recommendations to FDA. There is some evidence that the compounding functions of American pharmacists will be clearly defmed and permitted under conditions and limitations set forth by FDA. It is ironic that this is happening when there is an increased demand for compounded prescriptions and at a time when colleges of pharmacy have reduced the hours of instruction devoted to compounding. Extemporaneous compounding expands the pharmaceutical care concept in that it allows pharmacists to individualize the dose or dosage form to accommodate an individual patient. By compounding a prescription, a pharmacist practices his profession secundum artem. P. F. Belcastro, PhD, professor emeritus ofpharmaceutics, School ofPharmacy and Pharmacal Sciences, Purdue University, West lLlfayette, Ind. References 1. Gosselin R. Reflections-Part 4: pharmaceutical care. Drug Topics. 1995;139(13):10J. 2. Grady D. New fight over the old art of drug compounding. New York Times. July 6, 1999:D5. 3. Desai A, Usayapanat A, MacKinnon K, Stanaszek M. Integration of pharmacy practice and pharmaceutical sciences in developing an elective course in contemporary compounding. J Pharm Teach. 1998;6(4):39-46.
4. Food and Drug Administration Modernization Act of 1997. IntI J Pharm Compo 1998;2(1):32.
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Using the Internet for Research Bill G. Felkey and Shauna M. Buring
Objective: (1) To give an overview of research tools, techniques, and resources that are available on the Internet; and (2) to identify valid, pharmacy-related information that will reduce uncertainty in the problem-solving activities of practitioners. Data Sources: The World Wide Web. Study Selection: Examples cited in the article were evaluated according to the criteria offered in the text as a pre· requisite for their inclusion. Data Synthesis: Functional aspects of the Internet include communication, commerce, and content. Because a lack of control has led to mixed information quality, the use of Internet-based information for patient care and professional ,
I
decision making should be subject to rigorous screening criteria. Pharmacists can use Web browsers combined with excellent search engines and search techniques to identify quality resources, including primary, secondary, and tertiary literature, either fee-based or free, and that can be sought actively or distributed on a schedule directly to the desktop of the pharmacist. Conclusion: The Internet can be an immensely helpful research tool, if used appropriately. Whether actively searching or passively receiving useful updates, the Internet can function as a value-added asset to any pharmacy practice. JAm Pharm Assoc. 2000;40:546-53,
The pharmacist often serves as an information resource for patients and other health care professionals. Patients are increasingly bringing Web-based material to their pharmacists to interpret and evaluate, and to personalize its application to their lives. Unique opportunities exist for pharmacists to position themselves as the information purveyor on interdisciplinary health care teams. Assuming this role requires that pharmacists become highly skilled in the area of Internet research. This article is intended to help readers incorporate the Internet into their practice for the purpose of achieving greater efficiency, effectiveness, and satisfaction. The article focuses on those resources in the area of health care in general, and pharmacy specifically, that are readily available for practitioners' use.
Internet Functions The functions of the Internet can be categorized into the three C's: communication, commerce, and content. Communication is Received February 14, 2000, and in revised form April 30, 2000. Accepted for publication May 4, 2000. Bill G. Felkey, MS, is associate professor of pharmacy care systems; Shauna M. Buring, PharmD, is assistant professor of clinical pharmacy practice, School of Pharmacy, Auburn University, Auburn, Ala. Correspondence: Bill G. Felkey, MS, Auburn University, Department of Pharmacy Care Systems, 128 Miller Hall, Auburn University, AL 368495506. Fax: 334-844-8307. E-mail: [email protected].
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interchangeably referred to as connectivity andlor community, Commerce encompasses both business-to-business and businessto-consumer transactions. Content is an increasingly rich resource for reducing uncertainty in decision making as long as ) the pharmacist is aware of the quality issues associated with the content. Pharmacists must become skilled in identifying and separating the good from the bad.
Communication When most people think about communication via the Inter- 'I' IT net, they likely think of e-mail. However, the Internet provides communication capabilities that are far more sophisticated than simple messaging. Videoconferencing, chat rooms, news broad· ) I! casts, radio programs, and continuing education programs are 1p among the additional communication formats available. The u communication devices used to access the Internet continue to ~ weigh less and do more. Telemedicine technology and desktop u videoconferencing have been part of the reason that futurists P have proclaimed, "Death to Distance!"l In the United States, d Western Europe, and Japan, communication technologies have ~ become so integrated in daily life that computer illiteracy is anal- h ogous to an inability to drive a car. Being online full-time is rapidly becoming a requirement as basic as having a telephone. As health care becomes more "Net- ) ~ centric," or Web-based, these communication capabilities will continue to change the face of pharmacy until they are integral to
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VI
Using the Internet
successful and competitive practice. The clinical workstation to be used at the point-of-care, or the point at which the health care I practitioner interacts with a patient or colleague, can be a desktop computer, portable computer, palm computer, or even a wireless, portable system. A practitioner can begin incorporating the power of information technology and the Internet by selecting core medical and drug information references (e.g., Harrison's Online, Micromedex's DrugDex), creating a connection to the Web, and selecting additional clinical resources that are appropriate for daily practice (an example for patient education is www. healthanswers.com and for clinical practice guidelines, . www.guideline.gov). It would also be desirable to use a highbandwidth connection to the Internet, such as cable modem or digital subscriber line, if available. I I
I
Commerce (Mouse-to-House) Internet commerce is expected to continue to increase rapidly. In a recent online poll, 50% of the respondents had made an online purchase within the past 12 months, and 71 % planned to increase their use of the Internet as an e-commerce tool in the future. 2 The Internet is exploding, with news agencies reporting $5 billion in sales on the W orId Wide Web during the 1999 holiday season ~one. 3 Medical reference books, durable medical equipment, and medications (both"prescription and over-the-counter) are all availI able with the click of a mouse and a credit card.
IContent I
In 1998 Bill Gates, in a keynote speech for the Redmond, Washington, Conference on Information Technology, predicted that by the end of 1999 the Internet would hold more information than exists in the entire history of print for mankind. As of mid2000, there are more than 800 million Web pages. However, although the amount of content to choose from on the Internet is overwhelming, there are many ways to make the search process more efficient. The amount of medical and pharmaceutical information available on the Internet, for both health care professionals and patients, is immense-proprietary references, governmental information, practice guidelines, and a wide array of visual assets that can be Used to educate patients. Many major publishers have already converted their print resources for online access and made these offerings available on the Internet. Not only the text, but many of the previously offered CD-ROMs and network-version references and decision-support information resources are either currently or are SCheduled to be offered in a Web-based format. The next frontier is the integration of these content sources directly into practice illanagement and the electronic patient record, so that practitioners will not have to switch between programs to acquire the knowledge necessary to make decisions and solve problems. Remember that the intended purpose of all information is to reduce uncertainty. Effective Internet search strategies can help
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pharmacists locate key pieces of information to solve clinical problems. For example, often information is needed from the Food and Drug Administration (FDA) regarding new product approvals or market withdrawals. One can use a search engine and find the Center for Drug Evaluation and Research on the FDA home page (www.fda.gov/cder), then explore FDA's drug approval list for the time period of interest. While on this Web site, the user could also elect to receive information from the FDA on a daily or weekly basis. Knowing when the Internet should not be used for research is another valuable trait of the Internet researcher. Because of the relatively recent emergence of the Internet, Web sites may lack some historical information. Also, difficulty may be encountered when targeting news-related stories from proprietary sources that view the Internet as competition to their print publications. Some media publishers simply will not move their print products to electronic formats. However, this is expected to change over time, as the economic models on the Internet adjust. Information Quality
Evaluating the quality of information gleaned from the Internet is a crucial task for the Internet researcher. Because virtually anyone can post information on the Internet, it is important that health care providers view all information as suspect. Source credibility can be difficult to ascertain, but it must be verified. Furthermore, despite the broad perception that there are major inaccuracies in the health care information on the Web, designing research to study this problem is difficult. Evaluation of a large number of health care Web sites for accuracy is extremely time consuming, and there are no good studies published on this topic yet. The problem is more complex, and more urgent, because today patients are more involved in their own health care and frequently present information they have found on the Internet to their health care providers. Clinicians must be able to validate and screen this information for accuracy and appropriateness. Often, bias can creep into some information sites; therefore, it is important to know who is supplying the medical and pharmaceutical information and where the content originated. Site owners may have a vested interest in the content and hence give unbalanced information or promote individual products without divulging ownership of these products or other conflicts of interest. Therefore, users should know what to look for when evaluating the quality of a Web site. Below are specific items to look for or evaluate: • Authorship of the Web page and credentials of the content authors. • Quality of the references displayed with the content. Clinical information given with no reference to the source should receive low weight in clinical decision-making. • Disclosure of sponsorship and ownership of the Web site. • Frequency of updates, duration of time before important discoveries are incorporated into the content. • Presence of an expert advisory board that examines or evaluates content before it is displayed on the site.
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Using the Internet
• Presence of seals of approval awarded by organizations that actively review health care Web sites (e.g., Health on the Net Foundation HONcode [www.hon.ch]; Internet Healthcare Coalition [www.ihealthcoalition.org]; VIPPS [www.NABP.com]; and Medical Matrix [www.medmatrix.orgD.5- 7 • Affiliation of the Web site--commercial, governmental, educational, nonprofit, military or from an Internet service provider. Although these designations will not guarantee the source validity of the content on a Web page, they can give some indication of the source's credibility. 4
Internet Research Tools and lips Table 1 lists the selected Internet research resources described in this section. When other resources are desired, it is important to know how to effectively locate, organize, and evaluate them. A browser is the software application that allows a computer to navigate the World Wide Web. Microsoft's Internet Explorer 5 and Netscape's Navigator and Communicator, both offered free of charge, dominate the highly competitive browser market.a,b The similarity in features and benefits to end users of the two leading browsers enables users to go back and forth between the two applications with little difficulty. Knowledge of search engines is crucial when performing
research on the Internet. Search engines help users locate individu- I al Web sites by entering keywords, culminating in a list of sites that contain information related to the keywords. Most search engines have combination approaches that cross-reference key- I words and/or topic areas to assist users in fmding the most relevant I Web sites. Some search engines (e.g., AltaVista at www.altavista.com) have special features that allow Web sites 'I developed in a foreign language to be translated into English. AltaVista (see Figure 1) currently translates Web site contentto and from English, Spanish, German, Portuguese, Italian, and French. Mega-search engines (e.g., Metacrawler at www.metacrawler.com, Dogpile at www.dogpile.com) combine , several popular search engines into one research tool, pooling the top hits from each search engine. Because each search engine uses a different logic, using the Help feature teaches the user how to best employ the engine and fine-tune the results. These tutorials typically require only a few minutes and will save the user time later. Most search engines offer basic and advanced search windows, the ability to filter out undesirable characteristics of a site, and allow the use of Boolean operators, such as "and," "or," and "not" to further refme searches. Another timesaving tip when researching for the Internet is knowing how to locate the exact text keyword on an extensive Web page. A search may identify a promising site, but the user finds it contains 20 pages of text. By simultaneously pressing the "etrI" I
Table 1. Internet Research Resources Resource Category
Web Site Address
Features
Market research on health care topics
www.cyberdialogue.com/resource/ datawh ite_pa pers/1998/ma rketi ng_ cyberspace.html
White papers and survey results
Health care Web site seals of approval
www.hon.ch www.ihealthcoalition.org www.medmatrix.org
Valid Web information
Search engines
www.altavista.com www.metacrawler.com www.dogpile.com
Keyword and "meta" searching using a variety of search engines
Primary and secondary literature tools
www.nlm.nih.gov/databases/freemedl.html www.ovid.com/index.cfm www.nlm.nih.gov/databases/freemedl.html uncweb.carl.org uncweb.carl.org/reveal tendon.nlm.nih.gov/ld/loansome.html www.silverplatter.com/catalog/ipab.htm www.silverplatter.com/catalog/idis.htm webmedlit.silverplatter.com/index.html
Identify and/or retrieve full-text, peerreviewed literatu re
Tertiary literature
www.micromedex.com statref.tetondata.com www.mdconsult.com cp.gsm.com www.dynamicmedical.com
Monographs, textbooks, references
Health care news and issues services
www.usatoday.com/life/health/health.htm www.cnn.com/HEALTH www.msnbc.com/news/HEALTH_ Front.asp ?ta=y www.entrypoint.com www.intelihealth .com
Information for browsing or automatic notification
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Using the Internet
Figure 1. These sample screens illustrate the free translation capability of AltaVista's search engine by taking German text from an alternative medicine site and translating it into English. Caution should be used, because the translation may not be 1000/0 accurate. Some sentences can be poorly constructed by the application.
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Saving Web addresses requires some restraint, because hundreds of site addresses can be saved in a very short time. Also, both browsers offer the opportunity to organize these bookmarks into category folders. Each time the user locates a Web site that relates to a research interest, the browser allows that bookmark or favorite to be placed into the folder. Without this level of organization, it is easy to scroll through hundreds of Web sites looking for one found previously but not saved to a folder.
Access to the Scientific Literatu re ~.' f.t~..~ I.tOfMllri.tt4l",\t1\4.""n'l~h' fl,h'-itYl.I\t!ft\ll8ldlhi ft .tttItl4t'Wtittih
Primary Literature
Many reputable journals are published with open access on the Internet. Additionally, corporations (e.g., M OVID) are supplying full-text online access to key medical and pharmaceutical journals. Many health care providers gain access to MEDLINE via the OVID platform (www.ovid.com) and thus are provided with full'''''.'iitflllh, text access to a number of the most widely read medical journals. Providers should contact their medical librarian to determine which resources are available. Colleges of pharmacy may also allow preceptors and adjunct faculty members library privileges. However, many health care professionals access MEDLINE through the National Library of Medicine's (NLM ' s) PubMed platform (www .nlm.nih. govI databases/freemedl.html), which is free. Unfortunately, PubMed does not offer direct access I ;: to full-text articles online. UnCoverWeb and Loansome Doc are fee-for-service companies that supply full-text primary literature to a ... 1\' .. fax machine and/or desktop computer. UnCoverWeb (uncweb.carl.org) is an online article delivery service. . .. ... More than 8 million articles are available through a sim.......... ....... .*'i ple online order system. Through this site, a user can ri""' •. order journal articles online for a fee; the article is then ~~--~~~--~~~-----~~--~~~~~--~~~~~~~ ~ ~~------~----~~.~-~--~-----------------=~-~ faxed to the requester. Acquiring an article from the primary literature through UnCoverWeb costs $10 per article plus the copyright fee. Some medical libraries subsiI and "F' keys, a Find window will appear. Entering a keyword in dize this cost for authorized users. that text window and clicking the Find Next button highlights the A similar service, Loansome Doc (tendon.nlm.nih.gov/ldl keyword( s) being sought. This feature works on personal comput- loansome.html), is offered by NLM as a feature of PubMed. Users ers in both Internet Explorer and Netscape Communicator. can log into PubMed, search MEDLINE, and then order articles Sometimes, stopping an Internet research session is more diffi- from Loansome Doc. Loansome Doc users must first establish an I cult than starting one. When performing research on the Internet agreement with a medical library that uses DOCLINE, MEDfor a specific topic, it is not uncommon to fmd material that is of LINE' s automated interlibrary loan request and referral system. interest not only for the present search, but also for other topics. The user can then order articles from a list of retrieved citations I Internet Explorer and Netscape Communicator have a feature that and have full-text documents sent to the library. Some libraries I allows users to "bookmark" these sites for future research. Users may then transmit the article via the Internet, e-mail, or fax. The Can return to Web sites by creating and clicking on a bookmark. cost of the full-text article varies from library to library. UnCover Reveal (uncweb.carl.org/reveal) allows the health I In Microsoft's Internet Explorer, this feature is called a favorite. ~ ~.ttt"t'ttMd\t!till .. lhtolt!'l'lh)ntlft."
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Using the Internet
care professional to track the tables of contents of up to 50 journals. Each month an e-mailed notification of the tables of contents for selected journals is sent. This service can cost as little as $25 per year and is offered free in some library systems.
Figure 2. Medical Matrix (WlNW.medmatrix.org) presents researchers with ranked, peer-reviewed resources identi· fied from the Web. The credentials of the editorial board are disclosed and the service is free. Registration is required.
Secondary Literature
Secondary literature includes the abstracting and/or indexing services that organize millions of articles published in the primary literature. These resources include both proprietary and governmental resources (see Figure 2). The most frequently used database in medicine is MEDLINE (often searched by the PubMed search tool). PubMed provides access to the indexes and abstracts of more than 4,300 biomedical journals. It was developed in conjunction with publishers of biomedical literature as a search tool for accessing the primary literature and linking to full-text journals at Web sites of participating publishers. Other databases that are commonly used in pharmacy include International Pharmaceutical Abstracts (IPA) and the Iowa Drug Information Service (IDIS). IPA (www.silverplatter.com/catalog/ipab.htm) is a disciplinespecific database that indexes pharmaceutical science- and healthrelated journals and is available online as a component of the OVID platform. IDIS is a full-text database; the articles are stored on CD-ROM or microfiche (www.uiowa.edu/-idis).IDIS extracts articles from 190 leading medical and pharmacy journals. There are also many disease-specific databases that can be used in an Internet searching strategy. AIDSLINE (www.silverplatter. com/catalog/aidl.htm), which is supported by NLM, includes citations to the literature covering research, clinical aspects, and health policy issues related to AIDS. The citations are derived not only from journals, but also from AIDS-related meetings, such as the International Conference on AIDS. Commercial vendors such as WebMedLit and Medscape offer less traditional databases. WebMedLit (webmedlit.silverplatter. com/index.html) provides easy online access to the some of the best medical journals. The vendor scans selected medical Web sites each day and extracts the available citations, abstracts, and full-text articles. WebMedLit is arranged by disease state for easy searching. Medscape (www.medscape.com) is a multi-specialty medical information and education tool. Segmented by specialty, Medscape scans, filters, and collates pertinent content from online journals, summaries of professional meetings, and news in various specialty areas, including cardiology, internal medicine, and psychiatry. The National Guideline Clearinghouse (www.ahcpr.gov) is a comprehensive database of evidence-based clinical practice guidelines and related documents produced by the Agency for Health Care Policy and Research, in partnership with the American Medical Association and the American Association of Health Plans. Their mission is to provide health care professionals with information on clinical practice guidelines and to further the dissemination,
550 Journal of the American Phannaceutical Association
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implementation, and use of these practice guidelines. The National Guideline Clearinghouse can be an immensely useful tool in Internet research. The number of guidelines published by various professional organizations and governmental agencies is growing quickly. This resource helps users keep track of these guidelines by collating them in one site and organizing them by disease state.
1
Tertiary Literature
The category of tertiary literature includes review articles, textbooks, compendia, and full-text computerized databases. The advantage of using tertiary references is that the information has already been reviewed and condensed, so it is usually more compact and easy to examine. Historically, the disadvantage of this type of information was that it could be up to 3 years old before a new edition would be published. The Internet, however, makes it possible to update full-text tertiary databases on a daily basis, Before making patient care decisions based on the information contained in any resource, users should be confident concerning the source's credibility. There are many excellent proprietary references that are fee-based. Sponsorship has made it possible for other respected sources to be accessed free-of-charge. Additionally, an increasing amount of information categorized as news or medical issues information is being published on the Web. This is valuable for its "current awareness" value as well as for positi~n- ) ing pharmacists to discuss late-breaking health care issues WIth patients in a timely manner. Fee-based Resources. Fee-based tertiary literature in electronic formats was previously available only on CD-ROMs or network servers. Publishers have rapidly been creating Intranet versions of their products. The advantage of this kind of version is
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Using the Internet
the global access to the information with a valid ID and password. For example, the Micromedex product DrugDex (www. micromedex.com) has extensive drug information monographs that list the primary literature used to write the monograph. Other Micromedex databases included in the Micromedex product make it valuable for the emergency department physician and setting. Another database, STAT-Ref by Teton Data Systems (statref.tetondata. com) , contains more than 30 internationally recognized tertiary references. The product is available for Internet access and is capable of giving users access to one or all 32 references on any search. The references can be purchased individual) ly or in sets and placed on the health system Intranet for use. M.D. Consult (www.mdconsult.com) is the Internet product that contains the medical holdings of three large publishers, Lippincott Williams & Wilkins, Mosby, and W. B. Saunders Company. The product, which can be licensed by individuals for approximately $20 per month, contains more than 50 tertiary references, more than 500 published practice guidelines, patient education material, and more than 60 full-text journals. A 10-day free trial allows Internet researchers to examine the information offered before subscribing to the product. Free Online Resourcesrrextbooks. Hundreds of sites offer tertiary literature free-of-charge to both health care professionals and patients. Gold Standard Multimedia, Inc., (www.gsm.com) now offers Clinical Pharmacology 2000, which includes full-text drug infonnation monographs, free online, because their site is supported by advertising. This business model is likely to be followed increasingly, enabling access to information sources that would previously have cost several hundred dollars for a print I
publication or CD-ROM version of the same information. DynaMed (www.dynamicmedical.com). a free, disease-oriented Web site, is produced by physicians and other health care professionals as a point-of-care decision support tool (see Figure 3). The site displays a concise review of some 2,000 diseases and connects the user to other full-text journals and practice guideline resources on the Web. The National Institutes of Health has assembled a Web site for the National Center for Complementary and Alternative Medicine (nccam.nih.gov) that helps to address the need for an evidence-based approach to complementary and alternative medicine. This site is based on more than 180,000 primary literature references. Much of the clinical information presented on professional association and governmental sites is considered tertiary literature. In general, there is no fee for accessing this information. For example, the National Digestive Diseases Information Clearinghouse ( www.niddk.nih.gov/health/digestlnddic.htm) presents an overview of gastroesophageal reflux disease in a question/answer format that is quite descriptive. Some sites may be valuable for a health care provider's own edification or for referring patients who are eager to learn more about their conditions. One of the more recent developments on the Internet is the availability of free online textbooks. While many users prefer to have a print copy, online textbooks are valuable resources for reading limited amounts at one sitting. For example, a clinician seeking a refresher on the specific pathophysiology of esophageal motility could access Gold Standard Multimedia's online textbook Essentials of Human Physiology at imc.gsm.com. Because there is no one specific site that houses many online textbooks, search engines should be used to identify online texts in specific interest areas.
Figure 3. The DynaMed site offers a succinct, point-ofcare database that is updated daily. It addresses the management of more than 2,000 diseases and is free-ofcharge. ICD-9 codes, therapy considerations, etiology, and other subjects are addressed.
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Current Health Care News The mainstream and trade media frequently cover reports from major medical journals, such as JAMA and The New England Journal of Medicine. Additionally, many television news programs cover health care-related issues and often break stories that generate significant concern among the public. Therefore, it is important for health care providers to stay abreast of what the media reports to the public. One way of accomplishing this task is by reviewing a national newspaper or television site for the day' s health care issues. Print subscriptions are not necessary to access USA Toda y online (www. usatoday.com). Also, bookmarking the Health page provides quick access to the newspaper area of interest. Additionally' Cable News Network (CNN) (www.cnn.com) is a good Web site to use as a barometer of the health care issues before the public. The Internet is also valuable for accessing other topical programs, such as Dateline on MSNBC (www.msnbc.com). For example, Dateline recently aired a show about an autistic boy who was
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Using the Internet
given Secretin during an endoscopy and showed amazing improvement after the procedure. Shortly after this airing, pharmacies were flooded with questions about the product. Transcripts from the Dateline episode are available online and are extremely useful in such situations.
Figure 4. InteliHealth by Johns Hopkins offers a compre· hensive set of databases for consumer and practitioner use. It can send daily e-mail notices on health subjects of interest through a registration process. It contains special interest areas such as the women's health resources illustrated.
Push Technology It is easy to become overwhelmed by the amount of information found when searching the Internet. Hence several services personalize information and send it automatically or on demand. This service is called a "dialogue transaction" or "push technology," because the information is "pushed" by the service. EntryPoint (www.entrypoint.com). formerly PointCast, is a free service that allows you to select health care information and breaking news, information on pharmaceutical manufacturers, as well as sports, weather, financial information, and news about the Internet. By completing a filter form online, a user can request that information be limited to his or her interests. Johns Hopkins University and InteliHealth.com (www.intelihealth.com) offer a similar service that contains both professional and patient information for browsing, or users can fill out a profile and receive a daily e-mail containing news and developments in a given area of interest (see Figure 4). It is expected that this type of information dissemination will continue to increase as the Internet develops.
Fair Use and Copyrights Not all of the information on the Internet is in the public domain, even though the Internet can be readily accessed most anywhere on the planet. Many text and nonprint assets, such as pictures, sounds, and video vignettes, carry copyright protection. Much of the material on the Internet can still be used in a variety of different ways in practice. However, when the material captured from the Internet is used in a commercial venture, the line has been crossed between fair use and the need to pay a fee to the copyright holder. For example, many companies place information on the Internet that can be of value as a patient education resource. Using it directly from the Web site would not require any citation or attribution. However, copying the picture or quoting a portion of the material and combining it into your original work would require you to cite the author of the material and note the Internet address where the material originated or was acquired. When concern arises about whether something is a fair use, it is easy to use the e-mail feature on a Web site to request permission from the copyright holder. This usually entails a description of the intended use of the material. Use of the material in a commercial venture, such as creating a for-profit program for sale on the open market, will probably require the payment of a licensing fee. The
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United States Pharmacopeial Convention's Web site (www.usp.org) provides an example of a clear explanation on this line between free use and licensing. Although much of the content of their Web site is viewable by subscribers only, the site also contains quality photographs and useful information about dietary supplements that clinicians can download and use. At the bottom of their Web site is a Terms of Use section that informs the user that all materials are copyrighted. Any software downloaded from the site, including any files or images, and data are licensed by the United States Pharmacopeial Convention, Inc. It is stated that users are not allowed to "redistribute, sell, decompile, reverse, engineer, disassemble or otherwise reduce the software" to another format. 5 They further assert that this assumed agreement can only be superseded by an acknowledgment from them in writing that the requester has permission to use some of their content.
Conclusion The Internet can be an immensely helpful research tool if used appropriately. Whether one is actively searching or passively receiving useful updates, the Internet can function as a "valueadded asset" to a pharmacy practice. Learning when to use it, hoW to search for sites of interest, how to evaluate sites, and gaining insight into how the Internet can be used in practice are essential to the successful use of the Internet as a research aid.
----------------------------------------------- -Authorship of the article occurred following a consultancy to develop a PowerPoint presentation for Janssen Pharmaceutica through Carnes Communication for future presentations on the topic. The authors declare no
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References
Footnotes aMicrosoft Internet Explorer 5, the newest version of Internet Explorer is available at: www.microsoft.com/windows/ie/. bNetscape Communicator offers the complete set of tools for browsing dynamic Web content, and provides full-strength e-mail. Netscape Navigator is a browser that allows you to view Web sites. Available at: www.netscape.com/download/prodinfonfs_1.html.
1. Photo-News [Web sitel. Photofinishing News Letter. 1999;17(06). Available at: www.photo-news.com/pnI/1999-pnI/91122-PNL.htm. Accessed April 28, 2000. 2. Cyber Dialogue [Web sitel. Marketing Research in Cyberspace. Available at: www.cyberdialogue.com/resource/data/white_papers/ 1998/marketing_cyberspace.html. Accessed April 29, 2000. 3. PC Data Online [Web sitel. Consumer Internet Spending Tops $5 Billion During Holiday Season. Available at: www.pcdataonline. com/press/pcdo11300.asp. Accessed April 29, 2000. 4. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: caveat lector et viewor-Iet the reader and viewer beware. JAMA. 1997; 277:1244--5. 5. United States Pharmacopeia [Web sitel. Terms of Use. Available at: www.usp.org. Accessed February, 09, 2000.
Demise and Rebirth of Prescription Compounding in American Pharmacy Advances in science and technology during the 1900s led to the large-scale production of pharmaceutical preparations and dosage forms. As a result, phannacists compounded less and less. About 60% to 80% of all prescriptions were compounded during the 1930s and 1940s, but less than 1% required compounding during the 1960s. Hospital pharmacies began compounding intravenous solutions in the early 1970s. Currently, millions of large and small volume containers of parenteral solutions are compounded annually by trained technicians under the supervision of hospital phannacists. Gosselin 1 reported that in 1995 about 11 % of 220 million prescriptions were compounded in pharmacies that specialized in this activity. Two organizations 2 claiming thousands of members and franchises are based in Houston and assist pharmacies who wish to specialize in prescription compounding. Some phannacy schools 3 offer elective courses in prescription compounding, a recognized specialty in some states. During the last 15 years some hospital and community pharmacies "batch-compounded" prescriptions or preparations in quantities larger than those usually dispensed to an individual patient. In an attempt to define and perhaps regulate this kind of compounding, the Food and Drug Administration Modernization Acfl came into being in 1997. This act has become a congressional issue, and has triggered discussions among state boards of pharmacy and professional associations trying to protect the traditional compounding activities of phannacists. A Phannacy Compounding Advisory Committee has been appointed to make recommendations to FDA. There is some evidence that the compounding functions of American pharmacists will be clearly defmed and permitted under conditions and limitations set forth by FDA. It is ironic that this is happening when there is an increased demand for compounded prescriptions and at a time when colleges of pharmacy have reduced the hours of instruction devoted to compounding. Extemporaneous compounding expands the pharmaceutical care concept in that it allows pharmacists to individualize the dose or dosage form to accommodate an individual patient. By compounding a prescription, a pharmacist practices his profession secundum artem. P. F. Belcastro, PhD, professor emeritus ofpharmaceutics, School ofPharmacy and Pharmacal Sciences, Purdue University, West lLlfayette, Ind. References 1. Gosselin R. Reflections-Part 4: pharmaceutical care. Drug Topics. 1995;139(13):10J. 2. Grady D. New fight over the old art of drug compounding. New York Times. July 6, 1999:D5. 3. Desai A, Usayapanat A, MacKinnon K, Stanaszek M. Integration of pharmacy practice and pharmaceutical sciences in developing an elective course in contemporary compounding. J Pharm Teach. 1998;6(4):39-46.
4. Food and Drug Administration Modernization Act of 1997. IntI J Pharm Compo 1998;2(1):32.
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